Experts concerned about discrepancies in old, new PTSD criteria

Aug. 14, 2014 - 05:06PM
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Changes to the diagnostic criteria for post-traumatic stress disorder made in 2013 provide flexibility for new PTSD diagnoses in troops, but leave out some who would have been diagnosed with PTSD under the old standards, according to a new study published Thursday in the prestigious journal Lancet Psychiatry.

Researchers with the U.S. Army Military Operational Medicine Research Program surveyed 1,822 soldiers using checklists based on the old and new definitions of PTSD as spelled out in the Diagnostic and Statistical Manual of Mental Disorders, or DSM.

Roughly the same amount of soldiers screened positive for PTSD under the old DSM-4 criteria and new DSM-5 definition — 13 percent and 12 percent, respectively.

The same rang true for the 946 troops among the group who saw combat — 19 percent screened positive under DSM-4, while 18 percent did so under DSM-5.

But a significant portion of the troops who screened positive under one definition did not screen positive under the other, and vice versa.

Of the 221 soldiers who met DSM-4 criteria, 67, or 30 percent, did not meet the new criteria. And of the 216 soldiers who met DSM-5 criteria, 59, or 27 percent, did not meet the old criteria.

“The new PTSD symptom criteria do not seem to have greater clinical utility,” wrote retired Army Col. Charles Hoge and others. “Clinicians need to consider how to manage discordant outcomes, particularly for service members and veterans with PTSD who no longer meet criteria.”

In late 2012, the American Psychiatric Association Board of Trustees changed the requirements for diagnosing PTSD, redefining the disorder to allow for broader understanding of combat-related PTSD.

The group dropped a requirement that in order to receive a diagnosis, a patient must experience “fear, helplessness or horror” in reaction to a trauma or environmental stressor. Many military personnel don’t experience those reactions because they are trained to handle adverse events.

The researchers raised concerns that the differences in diagnoses may lead to a loss of access to care or disability support for troops with PTSD.

While the Defense and Veterans Affairs departments have policies upholding diagnoses made under the old criteria, “crucial questions remain” about the new definition, especially an implication that individuals who don’t screen for full-blown PTSD or those diagnosed under the old definition may be considered as having an adjustment disorder instead of an anxiety disorder, which PTSD is considered to be.

“This label carries a particularly pejorative connotation in the U.S. military, where adjustment disorder of less than six months can lead to administrative separation without benefits and chronic adjustment disorder conveys a message of weakness and failure to adapt,” Hoge wrote.

The researchers said their data raise questions about whether changing the definition actually will improve diagnosis and care for PTSD patients in the long run.

“Clinicians should recognize the subjectivity involved in developing consensus-based diagnoses, gather relevant assessment and clinical data and document which diagnostic criteria they apply,” they wrote.

In response to the Lancet Psychiatry article, psychiatrist and University of Adelaide professor Dr. Alexander McFarlane said the study shows the unintended consequences of tinkering with definitions.

Pointing out that the new definition also focuses largely on troops’ ability to voice their internal struggles and understand some of the emotions they are dealing — or refusing to deal — with, McFarlane said the new study “draws attention to the hazards the changes in diagnostic criteria will introduce in the administration of veterans benefits and access to care.”

“We think there should be a period of transition between legal use of DSM-4 and DSM-5 so the potential effects of these changes can be examined and deserving individuals are not denied their legal rights,” McFarlane wrote in a companion note in Lancet Psychiatry.